LISBON, Portugal – These days, Casal Ventoso is an ordinary blue-collar community — mothers push baby strollers, men smoke outside cafes, buses chug up and down the cobbled main street.
Ten years ago, the Lisbon neighborhood was a hellhole, a “drug supermarket” where some 5,000 users lined up every day to buy heroin and sneaked into a hillside honeycomb of derelict housing to shoot up. In dark, stinking corners, addicts — some with maggots squirming under track marks — staggered between the occasional corpse, scavenging used, bloody needles.
At that time, Portugal, like the junkies of Casal Ventoso, had hit rock bottom: An estimated 100,000 people — an astonishing 1 percent of the population — were addicted to illegal drugs. So, like anyone with little to lose, the Portuguese took a risky leap: They decriminalized the use of all drugs in a groundbreaking law in 2000.
___
EDITOR’S NOTE — This is part of an occasional series by The Associated Press examining the U.S. struggles in its war on drugs after four decades and $1 trillion.
___
Now, the United States, which has waged a 40-year, $1 trillion war on drugs, is looking for answers in tiny Portugal, which is reaping the benefits of what once looked like a dangerous gamble. White House drug czar Gil Kerlikowske visited Portugal in September to learn about its drug reforms, and other countries — including Norway, Denmark, Australia and Peru — have taken interest, too.
“The disasters that were predicted by critics didn’t happen,” said University of Kent professor Alex Stevens, who has studied Portugal’s program. “The answer was simple: Provide treatment.”
___
Drugs in Portugal are still illegal. But here’s what Portugal did: It changed the law so that users are sent to counseling and sometimes treatment instead of criminal courts and prison. The switch from drugs as a criminal issue to a public health one was aimed at preventing users from going underground.
Other European countries treat drugs as a public health problem, too, but Portugal stands out as the only one that has written that approach into law. The result: More people tried drugs, but fewer ended up addicted.
Here’s what happened between 2000 and 2008:
• There were small increases in illicit drug use among adults, but decreases for adolescents and problem users, such as drug addicts and prisoners.
• Drug-related court cases dropped 66 percent.
• Drug-related HIV cases dropped 75 percent. In 2002, 49 percent of people with AIDS were addicts; by 2008 that number fell to 28 percent.
• The number of regular users held steady at less than 3 percent of the population for marijuana and less than 0.3 percent for heroin and cocaine — figures which show decriminalization brought no surge in drug use.
• The number of people treated for drug addiction rose 20 percent from 2001 to 2008.
Portuguese Prime Minister Jose Socrates, one of the chief architects of Portugal’s new drug strategy, says he was inspired partly by his own experience of helping his brother beat addiction.

“It was a very hard change to make at the time because the drug issue involves lots of prejudices,” he said. “You just need to rid yourselves of prejudice and take an intelligent approach.”

Officials have not yet worked out the cost of the program, but they expect no increase in spending, since most of the money was diverted from the justice system to the public health service.

In Portugal today, outreach health workers provide addicts with fresh needles, swabs, little dishes to cook up the injectable mixture, disinfectant and condoms. But anyone caught with even a small amount of drugs is automatically sent to what is known as a Dissuasion Committee for counseling. The committees include legal experts, psychologists and social workers.

Failure to turn up can result in fines, mandatory treatment or other sanctions. In serious cases, the panel recommends the user be sent to a treatment center.

Health works shepherd some addicts off the streets directly into treatment. That’s what happened to 33-year-old Tiago, who is struggling to kick heroin at a Lisbon rehab facility.

Tiago, who requested his first name only be used to protect his privacy, started taking heroin when he was 20. He shot up four or five times a day, sleeping for years in an abandoned car where, with his addicted girlfriend, he fathered a child he has never seen.

At the airy Lisbon treatment center where he now lives, Tiago plays table tennis, surfs the Internet and watches TV. He helps with cleaning and other odd jobs. And he’s back to his normal weight after dropping to 50 kilograms (110 pounds) during his addiction.

After almost six months on methadone, each day trimming his intake, he brims with hope about his upcoming move to a home run by the Catholic church where recovered addicts are offered a fresh start.

“I just ask God that it’ll be the first and last time — the first time I go to a home and the last time I go through detox,” he said.

Portugal’s program is widely seen as effective, but some say it has shortcomings.

Antonio Lourenco Martins, a former Portuguese Supreme Court judge who sat on a 1998 commission that drafted the new drug strategy and was one of two on the nine-member panel who voted against decriminalization, admits the law has done some good, but complains that its approach is too soft.

Francisco Chaves, who runs a Lisbon treatment center, also recognizes that addicts might exploit good will.

“We know that (when there is) a lack of pressure, none of us change or are willing to change,” Chaves said.

___

Worldwide, a record 93 countries offered alternatives to jail time for drug abuse in 2010, according to the International Harm Reduction Association. They range from needle exchanges in Cambodia to methadone treatment in Poland.

Vancouver, Canada, has North America’s first legal drug consumption room — dubbed as “a safe, health-focused place where people inject drugs and connect to health care services.” Brazil and Uruguay have eliminated jail time for people carrying small amounts of drugs for personal use.

Whether the alternative approaches work seems to depend on how they are carried out. In the Netherlands, where police ignore the peaceful consumption of illegal drugs, drug use and dealing are rising, according to the European Monitoring Centre for Drugs and Drug Addiction. Five Dutch cities are implementing new restrictions on marijuana cafes after a wave of drug-related gang violence.

However, in Switzerland, where addicts are supervised as they inject heroin, addiction has steadily declined. No one has died from an overdose since the program began in 1994, according to medical studies. The program is credited with reducing crime and improving addicts’ health.

The Obama administration firmly opposes the legalization of drugs, saying that it would increase access and promote acceptance, according to drug czar Kerlikowske. The U.S. is spending $74 billion this year on criminal and court proceedings for drug offenders, compared with $3.6 billion for treatment.

But even the U.S. has taken small steps toward Portugal’s approach of more intervention and treatment programs. And Kerlikowske has called for an end to the “War on Drugs” rhetoric.

“Calling it a war really limits your resources,” he said. “Looking at this as both a public safety problem and a public health problem seems to make a lot more sense.”

There is no guarantee that Portugal’s approach would work in the U.S. For one, the U.S. population is 29 times larger than Portugal’s 10.6 million.

Still, an increasing number of American cities are offering nonviolent drug offenders a chance to choose treatment over jail, and the approach appears to be working.

In San Francisco’s gritty Tenderloin neighborhood, Tyrone Cooper, a 52-year-old lifelong drug addict, can’t stop laughing at how a system that has put him in jail a dozen times now has him on the road to recovery.

“Instead of going to smoke crack, I went to a rehab meeting,” he said. “Can you believe it? Me! A meeting! I mean, there were my boys, right there smoking crack, and Tyrone walked right past them. ‘Sorry,’ I told them, ‘I gotta get to this meeting.’”

Cooper is one of hundreds of San Franciscans who landed in a court program this year where judges offered them a chance to go to rehab, get jobs, move into houses, find primary care physicians, even remove their tattoos. There is enough data now to show that these alternative courts reduce recidivism and save money.

Nationally, between 4 and 29 percent of drug court participants will get caught using drugs again, compared with 48 percent of those who go through traditional courts.

San Francisco’s drug court saves the city $14,297 per offender, officials said. Expanding drug courts to all 1.5 million drug offenders in the U.S. would cost more than $13 billion annually, but would return more than $40 billion, according to a study by John Roman, a senior researcher at the Urban Institute’s Justice Policy Center.

The first drug court opened in the U.S. 21 years ago. By 1999, there were 472; by 2005, 1,250.

This year, new drug courts opened every week around the U.S., as states faced budget crises exarcebated by the high rate of incarceration on drug offenses. There are now drug courts in every state, more than 2,400 serving 120,000 people.

Last year, New York lawmakers followed counterparts across the U.S. who have tossed out tough, 40-year-old drug laws and mandatory sentences, giving judges unprecedented sentencing options. Also, the Department of Health and Human Services is training doctors to screen patients for potential addiction, and reimbursing Medicare and Medicaid providers who do so.

Arizona recently became the 15th state in the nation to approve medical use of marijuana, following California’s 2006 legislation.

___

In Portugal, the blight that once destroyed the Casal Ventoso neighborhood is a distant memory.

Americo Nave, a 39-year-old psychologist, remembers the chilling stories his colleagues brought back after Portuguese authorities sent a first team of health workers into the Casal Ventoso neighborhood in the late 1990s. Some addicts had gangrene, and their arms had to be amputated.

Those days are past, though there are vestiges. About a dozen frail, mostly unkempt men recently gathered next to a bus stop to get new needles and swabs in small green plastic bags from health workers, as part of a twice-weekly program. Some ducked out of sight behind walls to shoot up, and one crouched behind trash cans, trying to shield his lighter flame from the wind.

A 37-year-old man who would only identify himself as Joao said he’s been using heroin for 22 years. He has contracted Hepatitis C, and recalls picking up used, bloody needles from the sidewalk. Now he comes regularly to the needle exchange.

“These teams … have helped a lot of people,” he said, struggling to concentrate as he draws on a cigarette.

The decayed housing that once hid addicts has long since been bulldozed. And this year, Lisbon’s city council planted 600 trees and 16,500 bushes on the hillside.

This spring they’re expected to bloom.

LIMBE, Haiti – A gray-haired woman, her eyes sunken and unfocused from dehydration, stumbles up a dirt path slumped on the shoulder of a young man, heading to a rural clinic so overcrowded that plastic tarps have been strung up outside to shade dozens who can’t fit inside.
On the path to the clinic, another cholera victim lies dazed, her head bleeding because she couldn’t stay atop the motorcycle taxi that carried her along the twisting country roads to the treatment center on the front line of Haiti’s sudden battle with cholera.
Nearby, a 16-month-old girl wails as a nurse prods her with a needle, trying to find a vein for the intravenous fluids she needs to save her life.
Many feared Haiti’s growing epidemic would overwhelm a capital teeming with more than 1 million people left homeless by January’s earthquake. But, so far, it is the countryside seeing the worst of an epidemic that has killed nearly 1,900 people since erupting less than two months ago.
Rural clinics are overrun by a spectral parade of the sick, straining staff and supplies at medical outposts that could barely handle their needs before the epidemic.
At the three-room clinic near Limbe, in northern Haiti, a handful of doctors and nurses are treating 120 people packed into three rooms.
“It’s really attacking us,” Guy Valcoure, grandfather of the 16-month-old, says of the cholera. He piled on the back of a motorcycle with the baby and her mother to make a 40-minute ride in pre-dawn gloom to reach the clinic.
Holding a plastic cup in case his granddaughter gains enough strength to drink some water, Valcoure watches anxiously as a nurse tries without success to find a vein to give her intravenous fluids. Eventually, a doctor manages to get an IV into the baby’s foot. “She’s going to be OK,” the nurse tells Valcoure.
Not everyone is so fortunate. It was too late to save an old woman carried to the clinic on a door over the weekend, says Dr. Benson Sergiles, a doctor from Cap-Haitien on loan to the clinic. “It’s getting worse by the day,” he says, his eyes bleary from being up all night.
And experts say the disease has not yet reached its peak.
The Health Ministry says there have been more than 80,000 cases since cholera was first detected in late October and the Pan-American Health Organization projects it could sicken 400,000 people within a year.
A makeshift clinic run by the aid group Doctors Without Borders in Cap-Haitien is seeing 250 patients a day and expects two or three times as many in coming weeks, said Dr. Esther Sterk, a physician from the Netherlands in charge of the treatment center in a crowded gymnasium.
The cases are also rising further into the countryside, as at the little clinic near Limbe.
“I don’t think we’re anywhere near the end of this,” said Dr. John Jensen, a Canadian doctor volunteering with his wife, a nurse, for nearly a month at the clinic about 12 miles (20 kilometers) west of Cap-Haitien.
Fear over the spread of cholera even triggered a violent witch-hunt in the remote southwestern Grand Anse region, where locals have killed at least 12 neighbors on suspicions they used “black magic” to infect people, national police spokesman Frantz Lerebours said Thursday.
Cholera made its first appearance on record in Haiti near the central town of Mirebalais. From there it spread north through the Artibonite region. It has sickened thousands in the capital, but it is the vast rural population that is most vulnerable because cholera is spread by bacteria in contaminated water, and poor rural people often have no access to clean water and no clinics nearby.
“Most Haitians live in rural areas and most don’t have latrines,” said Dr. Louise Ivers of the medical aid group Partners in Health. “Most people have to do their business in a hole in the back garden and drink water from an unprotected source.”
It is these people who have the fewest options when they get sick. “Why do you die from cholera? Because you don’t have access to health care,” Ivers said.

A hospital in the central Haitian city of Maissade has just two physicians to care for a population of 60,000. That center along had treated 350 cholera patients as of last week, said Dr. Tim Rindlisbacher of Toronto, Canada, who recently worked there as a volunteer with the Canadian aid group Humanity First.

He said he believes many more never got treatment.

“It is easy to miss it in the rural areas,” Rindlisbacher said. “There’s a lot of people who never make it to a hospital, never make it to a doctor and there’s no way of tracking those people.”

In much of the countryside, public transportation is rare. The nearest doctor or nurse could be a trek of many hours through the mountains. Even in the cities, ambulances don’t exist and cholera patients usually travel by taxi or collective transport.

Associated Press journalists this week came upon four men carrying a 14-year-old boy on a stretcher along a dirt road, his mother trudging alongside. They had been walking four hours from their village to the town of Grand Riu Du Nord, in mountains about 16 miles (25 kilometers) south of Cap-Haitien to reach a clinic staffed by Cuban doctors, who treated the boy.

A maddening fact about cholera, which rapidly drains the bodily fluids from its victims, is that it is easy to treat and most people survive if they get medical attention. Doctors Without Borders says the disease has a mortality rate of less than 1.5 percent among people who reach the more than two dozen treatment centers it operates around Haiti.

Yet no one knows how many are dying uncounted and alone out in the countryside.

One small village visited by Guytho Alphonse, a public health promoter for the aid group Oxfam, is a three-hour walk from the nearest medical clinic. He said villagers told him that an entire family of six had died of the disease. His visit was meant to prevent such tragedies: he was distributing oral rehydration mixture and chlorine for treating wells.

Dr. Thony Michlet Voltaire, who runs a hospital in the town of Sante Borgne, about 40 miles (65 kilometers) from Cap-Haitien, said he was getting 40 patients a day. He said seven people had arrived in such bad shape over the past week that they could not be saved.

“A lot of people are dying at home because they can’t make it to us,” said Voltaire, who said his clinic, the Alliance Sante Borgne, was in dire need of medicine, volunteers and such basic supplies as clean bed sheets.

Aid groups and international organizations such as the United Nations are working on campaigns to confront the outbreak, but Ivers and others said it will take an army of health workers to stop cholera’s spread.

“Let me put it this way: We have 3,000 community health workers and we are hiring more … as many as we can,” she said.

PORT-AU-PRINCE, Haiti – Protests over the cholera epidemic faded Friday but young men burned tires and threw rocks at police near government buildings amid surging anger over a disease that has killed more than 1,100 people so far.
Frustrations simmered as the medical aid group Doctors Without Borders issued a statement that “despite the huge presence of international organizations in Haiti, the cholera response has to date been inadequate in meeting the needs of the population.”
The aid group, which has been one of the primary responders to the epidemic, said that other international organizations have failed to provide enough safe water or soap, build enough latrines and waste disposal sites, or remove dead bodies. It also criticized groups for not reassuring people that the disease is treatable.
Cholera had never before been confirmed in Haiti, and fears spurred by the arrival of the disease have led to attacks on treatment facilities and riots against U.N. peacekeepers who many suspect of having brought the disease to Haiti.
Friday’s small-scale protest in the capital, Port-au-Prince, was far more muted than those of the day before, when demonstrators’ attacked foreigners’ cars. In the northern city of Cap-Haitien, the country’s second-largest, several days of protests left three people dead and virtually shut off medical aid to cholera sufferers there.
It was quiet in Cap-Haitien on Friday: Local authorities cleared road barricades, allowing medical aid to flow back into the city, while relatives of cholera victims carried coffins. An Associated Press cameraman saw several corpses lying on the streets.
The area has the highest fatality rate in the country, with 7.5 percent of people who are hospitalized succumbing to the infection.
U.N. humanitarian agencies had appealed for a halt to the demonstrations, saying that lives were being lost because they could not reach people who needed care.
The upheaval over the cholera outbreak that has killed comes just days before national elections planned for Nov. 28. U.N. officials argue that the violence is being encouraged by forces that want to disrupt the ballot, and some demonstrators Thursday threw rocks at an office of President Rene Preval’s Unity party and tore down campaign posters.
But the anger is fueled by suspicions that a contingent of Nepalese soldiers brought cholera with them to Haiti and spread the disease from their rural base into the Artibonite River system, where the initial outbreak was centered last month. It is a suspicion shared by some prominent global health experts.
Cholera had not been recorded before in Haiti despite rampant bad sanitation and poor access to drinking water, problems that cause outbreaks of the disease in other parts of the world. Cholera is endemic to Nepal and there was an upsurge there before the Nepalese troops came to Haiti.
The disease had spread to Haiti’s national prison in Port-au-Prince, International Red Cross spokesman Marcal Izard said Friday in Geneva.
Izard said 30 inmates have been infected with the diarrheal disease and 10 have died in the past four days. The prison holds 2,000 inmates, or about a quarter of Haiti’s total prison population.
The disease is spread by contaminated fecal matter. Health experts say it can be easily treated with rehydration or prevented outright by ensuring good sanitation and getting people to drink only purified water.
But after years of instability, and despite decades of development projects, many Haitians have little access to clean water, toilets or health care.
___
Associated Press writers Evens Sanon in Port-au-Prince, Pierre-Richard Luxama in Cap-Haitien and Ezequiel Abiu Lopez in Santo Domingo, Dominican Republic, contributed to this report.

PORT-AU-PRINCE, Haiti – Haitians angry over the cholera epidemic ignored exhortations from health workers to stop violence that is disrupting treatment efforts, and authorities feared more unrest in the capital Friday.
Violence spread into Port-au-Prince for the first time Thursday after three days of upheaval in the country’s north. Protesters threw rocks at U.N. peacekeepers, attacked foreigners’ cars and blocked roads with burning tires and toppled light poles.
The upheaval over a cholera outbreak that has killed more than 1,100 people comes just days before national elections planned for Nov. 28. U.N. officials argue that the violence is being encouraged by forces that want to disrupt the ballot, and some demonstrators Thursday threw rocks at an office of President Rene Preval’s Unity party and tore down campaign posters.
But the anger is fueled by suspicions that a contingent of Nepalese soldiers brought cholera with them to Haiti and spread the disease from their rural base into the Artibonite River system, where the initial outbreak was centered last month. It is a suspicion shared by some prominent global health experts.
Cholera had not been recorded before in Haiti despite rampant bad sanitation and poor access to drinking water, problems that cause outbreaks of the disease in other parts of the world. Cholera is endemic to Nepal and there was an upsurge there before the Nepalese troops came to Haiti.
Experts have not pinpointed the origin of Haiti’s epidemic, however, and the 12,000-member U.N. Stabilization Mission in Haiti, or MINUSTAH, denies responsibility.
U.N. peacekeepers have been the dominant security force in Haiti for six years, and there was resentment against them even before the cholera outbreak.
Standing before the thick black smoke of blazing tires Thursday, protesters in Port-au-Prince yelled “We say no to MINUSTAH and no to cholera.” Some carried signs reading “MINUSTAH and cholera are twins.” The windows of several cars belonging to the United Nations and to humanitarian groups were broken.
“It’s not only that (the U.N. peacekeepers) have to leave but the cholera victims must get paid (damages),” said Josue Meriliez, one of the demonstrators.
Haitian police fired tear gas at the protesters on the central Champ de Mars plaza, and clouds of choking irritants blew into nearby tent shelters of thousands made homeless by the Jan. 12 earthquake.
Protesters also threw rocks at a motorcade leaving the national palace, which fired warning shots to clear a path. It was not immediately known if President Rene Preval was in the motorcade.
Aid workers, including U.N. humanitarian agencies that are structurally separate from the peacekeeping force, have been calling for calm, saying the violence is hampering efforts to treat the tens of thousands of people stricken with cholera.
The disease is spread by contaminated fecal matter. Health experts say it can be easily treated with rehydration or prevented outright by ensuring good sanitation and getting people to drink only purified water.
But after years of instability, and despite decades of development projects, many Haitians have little access to clean water, toilets or health care.
In the neighboring Dominican Republic, health authorities launched a nationwide search Thursday for people suffering from symptoms typical of cholera: diarrhea, vomiting and dehydration.
Health Minister Bautista Rojas said hundreds of doctors, epidemiologists and other medical officials will be going “house by house, in each sector, neighborhood and alleyway,” looking for any trace of an outbreak.
They will interview neighbors, offer medical care and, if necessary, take anyone suspected of having cholera to the hospital.
The Dominican Republic has stepped up health measures to try to keep the epidemic from crossing the border — especially after the nation’s first cholera case was detected Monday in an immigrant brick worker who returned sick after a vacation in his Haitian homeland.

Dominican authorities have increased border patrols and monitoring of frontier crossings. The two nations share the Caribbean island of Hispaniola.

___

Associated Press writer Evens Sanon in Port-au-Prince and Ezequiel Abiu Lopez in Santo Domingo, Dominican Republic, contributed to this report.

PORT-AU-PRINCE, Haiti – Protesters in Haiti’s capital are lashing out at U.N. peacekeepers and the government, blocking roads and attacking foreigners’ vehicles.
Demonstrators are setting up burning barricades, and Haitian police have fired tear gas.
U.N. and non-governmental organization vehicles have been pelted with rocks.
The growing protest comes a week before national elections, and marchers are destroying campaign posters for President Rene Preval’s Unity party.
It follows days of rioting in northern Haiti over suspicions that U.N. soldiers introduced a cholera epidemic that has killed more than 1,000 people.
The U.N. military mission denies responsibility for the epidemic.